Type 2 diabetes mellitus in older people: a brief statement of key principles of modern day management including the assessment of frailty. A national collaborative stakeholder initiative

Rates of population ageing are unprecedented and this, combined with the progressive urbanization of lifestyles, has led to a dramatic shift in the epidemiology of diabetes towards old age, particularly to those aged 60-79 years. Both ageing and diabetes are recognized as important risk factors for the development of functional decline and disability. In addition, diabetes is associated with a high economic, social and health burden. Traditional macrovascular and microvascular complications of diabetes appear to account for less than half of the diabetes-related disability observed in older people. Despite this, older adults are under-represented in clinical trials. Guidelines from organizations such as the National Institute for Health and Care Excellence (NICE), the European Association for the Study of Diabetes, and the American Diabetes Association acknowledge the need for individualized care, but the glycaemic targets that are suggested to constitute good control [HbA_1c 53-59 mmol/mol (7-7.5%)] are too tight for frail older individuals. We present a framework for the assessment of older adults and guidelines for the management of this population according to their frailty status, with the intention of reducing complications and improving quality of life for these people.

Research gaps in the management and prevention of cutaneous squamous cell carcinoma in organ transplant recipients

Although tremendous progress has been made in recent years in skin cancer care for organ transplant recipients, significant gaps remain in data-driven clinical guidelines, particularly for the treatment and prevention of cutaneous squamous cell carcinoma (cSCC), the most common malignancy among this population. In this review, we aim to summarize current knowledge around the management of cSCC and highlight the most significant gaps in knowledge that continue to pose challenges in the delivery of skin cancer care for organ transplant recipients. We suggest future directions for research that will bridge existing gaps and establish evidence-driven guidelines for primary prevention, screening and treatment of cSCC in this high-risk patient population.

A simulated rugby match protocol induces physiological fatigue without decreased individual scrummaging performance

Background: A rugby union game consists of 80 minutes of strenuous exertion. Forwards are required to participate in the arduous activity of scrummaging throughout a game.Objectives: The purpose of this study was to identify whether rugby-match simulated fatigue modified individual scrummaging technique and reduced performance.Methods: Twelve forwards (body mass 106.2±13.3 kg; stature 179.5±8.4 cm) had individual scrum kinetics and kinematics assessed prior to and following a protocol that simulated a rugby match. The simulated rugby match protocol required participants to run at various velocities and perform rugby specific tasks. Rating of Perceived Exertion (RPE) was assessed using a 6-20 Borg scale and Visual Analogue Scale (VAS). Blood lactate, heart rate and RPE were measured prior to, at mid-point and after the simulated game, while markers of muscle damage (blood creatine kinase activity (CK) and urea) were measured prior to and following the protocol.Results: RPE (p<0.0001) and VAS (p<0.0001) showed significant increases between the pre- and post-simulation values. Of the physiological markers, heart rate (p<0.0001) and blood urea concentration (p=0.004) increased following the match simulation. No significant differences were observed for blood CK (p=0.281), individual scrummaging forces (p=0.433) or in the kinematic variables following the protocol. While physiological fatigue and subjective ratings of physiological fatigue may develop during a rugby simulation, no differences were observed in peak forces or in body kinematics at peak force.Conclusion: Physiological fatigue does not influence individual scrummaging performance and technique.

History of Depression in Lung Cancer Patients: Impact of Delay

AIMS

To examine the influence of a history of depression in the process of diagnostic evaluation and the choice of treatment in lung cancer.

MATERIALS AND METHODS

The analysis was based on all patients with non-small cell lung cancer who were registered in 2008-2014; in total, 27 234 patients. To estimate the effect of depression on the diagnostic process and the choice of treatment in lung cancer we fitted a logistic regression model and a Cox regression model adjusting for age, gender, resection and stage.

RESULTS

Depression in a patient's anamnesis had no significant effect on the delay in diagnostic evaluation (hazard ratio = 0.99 with 95% confidence interval 0.90; 1.09). Patients with a history of periodic depression had a 33% lower treatment rate (odds ratio = 0.66 with 95% confidence interval 0.51; 0.85) than patients without a history of depression.

CONCLUSIONS

Our study shows that patients with a history of periodic depression need special attention when diagnosed with lung cancer.

Association between microfibrillar-associated protein 4 (MFAP4) and micro- and macrovascular complications in long-term type 1 diabetes mellitus

AIMS

To evaluate microfibrillar-associated protein 4 (MFAP4) as a marker of micro- and macrovascular complications in patients with type 1 diabetes.

METHODS

This cross-sectional study included 203 persons with a long duration of type 1 diabetes from a population-based cohort ascertained in the former Funen County, Denmark. Detection of plasma-MFAP4 (pMFAP4) was performed by the AlphaLISA Technique. Diabetic retinopathy (DR) was graded in accordance with the Early Treatment Diabetic Retinopathy Study adaptation of the modified Airlie House classification. A monofilament test was used to test for neuropathy, and nephropathy was evaluated in a single spot urine sample. Data describing macrovascular disease were obtained from the Danish National Patient Register.

RESULTS

Median age and duration of diabetes were 58.7 and 43 years, respectively, and 61% were males. High levels of pMFAP4 were found in participants of old age, in women and in non-smokers (p < 0.05). In a multiple logistic regression model, patients with high levels of pMFAP4 were more likely to have diabetic neuropathy (OR 2.47 for quartile 4 versus quartile 1, 95% CI 1.01-6.03). No association was found between pMFAP4 and proliferative diabetic retinopathy, nephropathy or macrovascular disease.

CONCLUSIONS

No association between pMFAP4 and macrovascular vascular complications was found. However, high levels of pMFAP4 correlated independently with diabetic neuropathy. Further studies on the predictive value of increased circulating MFAP4 in diabetic neuropathy are warranted.